Diagnostic challenges in alcohol use disorder and alcoholic liver disease

Table 1 Diagnostic and Statistical Manual of Mental Disorders-5 criteria for alcohol use disorders

Criterion	Group
1	Impaired control	The individual may take alcohol in larger amounts or over a longer period than was originally intended
2		The individual may express a persistent desire to cut down or regulate alcohol use and may report multiple unsuccessful efforts to decrease or discontinue use
3		The individual may spend a great deal of time obtaining alcohol, drinking alcohol, or recovering from its effects
4		Craving is manifested by an intense desire or urge for alcohol that may occur at any time but is more likely when in an environment where alcohol previously was obtained or used
5	Social impairment	Recurrent alcohol use may result in a failure to fulfil major role obligations at work, school, or home
6		The individual may continue alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol use
7		Important social, occupational, or recreational activities may be given up or reduced because of alcohol use. The individual may withdraw from family activities and hobbies in order to use alcohol
8	Risky use	This may take the form of recurrent alcohol use in situations in which it is physically hazardous
9		The individual may continue alcohol use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
10	Pharmacological criteria	Tolerance, as defined by a need for a markedly increased dose of alcohol to achieve the desired effect or by a markedly reduced effect when the usual dose is consumed
11		Withdrawal, that is a syndrome that occurs when blood or tissue concentrations of alcohol decline in an individual who had maintained prolonged heavy alcohol use

Table 2 CAGE questionnaire

1	Have you ever felt you should cut down on your drinking?
2	Have people annoyed you by criticizing your drinking?
3	Have you ever felt bad or guilty about your drinking?
4	Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Each response is scored as 0 or 1, with a higher score indicative of alcohol-related problems and a total of 2 or more clinically significant.

Table 3 Alcohol use disorders identification test

	Questions	0	1	2	3	4
1	How often do you have a drink containing alcohol?	Never	Monthly or less	2 to 4 times a month	2-3 times a week	4 or more times a week
2	How many drinks containing alcohol do you have on a typical day when you are drinking?	1 or 2	3 or 4	5 or 6	Weekly	10 or more
3	How often do you have six or more drinks on one occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
4	How often during the last year have you found that you were not able to stop drinking once you had started?	Never	Daily or almost daily	Monthly	Weekly	Daily or almost daily
5	How often during the last year have you failed to do what was normally expected from you because of drinking?	Never	Daily or almost daily	Monthly	Weekly	Daily or almost daily
6	How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?	Never	Daily or almost daily	Monthly	Weekly	Daily or almost daily
7	How often during the last year have you had a feeling of guilt or remorse after drinking?	Never	Daily or almost daily	Monthly	Weekly	Daily or almost daily
8	How often during the last year have you been unable to remember what happened the night before because you had been drinking?	Never	Daily or almost daily	Monthly	Weekly	Daily or almost daily
9	Have you or someone else been injured as a result of your drinking?	No		Yes, but not in the last year		Yes, during the last year
10	Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?	No		Yes, but not in the last year		Yes, during the last year

Table 4 Fibrosis staging systems

Stage	Metavir	Kleiner
0	No fibrosis	No fibrosis
1	Stellate enlargement of portal tract, but without septa formation	Perisinusoidal or periportal
		1A: Mild, zone 3, perisinusoidal
		1B: Moderate, zone 3, perisinusoidal
		1C: Portal/periportal
2	Enlargement of portal tract but with rare septa formation	Perisinusoidal and portal/periportal
3	Numerous septa without fibrosis	Bridging fibrosis
4	Cirrhosis	Cirrhosis